Abstract

A small, city-wide clinical outreach service for the homeless mentally ill
in Sheffield, UK, attained its present configuration 6 years ago. This paper
discusses the lessons learnt in the course of the service’s
existence.

The homeless mentally ill identified by the service have disengaged from
the ‘mainstream’ services and society. Most are from disturbed
homes, nearly all have had prior contact with psychiatric services and as many
as half have served prison terms. As service users, they must be actively
sought out and engaged, which places specific demands upon a mental health
team: flexibility of approach, patience and a willingness not to judge
others’ values.

Though largely anecdotal, the inferences drawn in Sheffield may have
parallels elsewhere, not least since individual lives can turn upon pivotal
(‘anecdotal’) encounters and those evinced by the homeless tell us
much about society, psychiatry and the values of contemporary healthcare
providers. Also, most of the time, the proposed model has been successful.

If taken at face value, it seems obvious that publicly funded healthcare
providers should undertake to deliver care to those who are the most
impoverished. Few are more impoverished than the homeless mentally ill.
However, some features of this social group and the care providers they
encounter can impede satisfactory service delivery.

Sheffield is a post-industrial city in the north of England with a
population in excess of half a million. Traditionally reliant upon the steel
industry, and having suffered the depredations of its collapse and that of the
coal industry in the 1980s, the city has recently diversified into service
provision and advanced technologies. Demographically very similar to the
English average, Sheffield’s population is predominantly White, with a
large Asian minority and many other ethnic groups represented. The
city’s two universities employ and educate a large proportion of the
total population.

Homeless Assessment and Support Team

Each year, the Sheffield City Council categorises over 3000 people as ‘
homeless’ (i.e. approximately 0.5% of the population). In most
cases, such people reside in temporary accommodation and only a small number
(less than 100) are literally ‘roofless’ (Sheffield City Council).
The Homeless Assessment and Support Team seeks to engage with, support and
treat those who are homeless and mentally ill, with a view to achieving two
tangible outcomes:

acquisition of permanent accommodation

access to ‘mainstream’ mental health services.

Growing out of a general practice project piloted in the early 1990s, the
service for the single homeless individual is now jointly funded by the local
authority and a National Health Service (NHS) mental health trust. It
comprises three full-time equivalent keyworkers (one nurse and three social
workers, two of whom are half-time), a part-time secretary, as well as input
from a larger team’s service manager and a consultant psychiatrist (a
university-funded academic) who spends two sessions per week with the team.
This ‘singles’ team works across Sheffield and forms the focus of
this report. There is a ‘families’ team too, comprising health
visitors and nurses, but it is not described here.

Finding the homeless

Referrals to the Homeless Assessment and Support Team come from a wide
variety of sources: local authority housing officers; workers at hostels,
housing associations, ‘interim accommodations’, bed and breakfast
hotels, ‘drop-in’centres; general practitioners, health visitors,
keyworkers from the local substance-misuse service, probation officers and
occasionally the relatives of those who are ‘missing’. One member
of the team has a specific remit to engage with ‘rough sleepers’
and actively seeks out those who are roofless (there are key locales where
such people are likely to be found). There are approximately 300 referrals per
annum (about 10% of the homeless population) and at any time the team will be
in touch with approximately 100 individuals, of whom 30–40 are also
under the care of the team’s psychiatrist.

We have audited our clinical diagnoses annually for the past 6 years and
the figures have been remarkably stable: approximately half of the homeless
have depression, 20% have psychoses (including schizophrenia), 30–50%
have concurrent alcohol problems, a similar number have dual diagnoses
(affective or psychotic disorder plus substance misuse) and 20% primarily have
personality disorders. There are also usually approximately 10% with learning
disabilities and a small number of other organic syndromes (Huntington’s
disease, dementias, Korsakoff’s syndrome and Asperger syndrome). The
majority are male (more than 80%), in their thirties; 20% will have been
raised in ‘local authority care’, 10% attended ‘special
schools’; most (70–90%) have used psychiatric services previously,
with 40–70% having been admitted to hospital and 20–30% formally
detained (under various sections of the 1983 Mental Health Act); 25–50%
have history of violence; similar percentages have self-harmed and served
prison sentences. Between 5 and 10% describe childhood sexual abuse but many
more describe violence and unhappiness experienced as children. Most service
users spend between 6 weeks and 6 months in contact with the team. The
team’s failed appointment rate has been 20% annually (when formally
audited, over the past 3 years) and we eventually lose 25% from follow-up
(often because users moved out of the city). Neither of these figures is
particularly high, relative to the literature
(Mitchell & Selmes,
2007).

Naturally, such a sample is likely to be highly selected. Those referred
are not only homeless, they are also (in the main) referred by professionals
who do not specialise in psychiatry, hence they might well comprise those most
likely to attract attention, for example through disturbed behaviour, confused
speech, depressed affect, demonstrable self-harm or gross neglect
(Bittner, 1967). It is quite
possible that those who are ‘quietly ill’ are systematically
under-referred. However, sometimes a minor aberration serves to reveal someone
who has fallen through the net: a person with Asperger syndrome who had always
lived with their parents was arrested for stealing a tin of baked beans
following their deaths (there was no one left to look after them); a person
with dementia arrived at a railway station, carrying an empty suitcase, with
only a crumpled letter from a mental health trust to identify them; a young
woman with psychotic depression was found sleeping in a graveyard (she was
listening to the voice of her ‘dead brother’, who was later traced
and found to be alive); another young woman drew attention to herself in a
hostel because the taps in her room were running all night – she had
obsessive–compulsive disorder and was washing her hands continually; a
young man with schizophrenia, who had lived almost his entire adult life on
the street, known to police through his well-meaning acts of generosity (he
was not an offender), only attracted referral when he developed choreiform
movements, etc. Many of these occurrences are singular, yet they have one
thing in common – in order for these people to be seen and helped, there
has to be a service that will go out to find them; they will not be
encountered in conventional out-patient clinics
(Timms, 1996;
Appleby, 2000;
Mitchell & Selmes, 2007).
Over the past 6 years we have interviewed people in hostels, bed and breakfast
hotels, women’s refuges, squats, drop-in centres, probation offices,
police stations, general practices, public houses, cathedrals, snooker halls,
graveyards, parks, alleyways, stairwells, railway sidings and wrecked cars. A
homeless service needs to be adaptable.

What other lessons can we learn from the homeless?

Although health and social care workers in many of Britain’s cities
may have grown used to meeting individuals with post-traumatic stress disorder
consequent upon torture in their mother countries
(Summerfield, 2002;
Tribe, 2002), it may be
surprising to learn that torture is also a domestic phenomenon. We have seen
people held and abused for days by drug dealers and other criminals, but also
by other homeless individuals. Often neither the perpetrator nor the victim
volunteers a reason for abuse, although sometimes it may be sexual. This
places particular demands upon a small team where the same professionals are
likely to see the perpetrator for one form of assessment (the post
hoc identification of forensic risk) and the victim for another (newly
identified as vulnerable). It is here that we have benefited immensely from
the multi-agency, public protection and planning framework, where access to
police information may be most enlightening (especially where there have been
previous offences that were not pursued through the courts).

Torture is relatively uncommon. More frequent are the casual acts of
violence meted out to the homeless on the streets (e.g. beating up by groups
of passers-by) or the punishments dispensed in certain subcultures (e.g. for
infidelity, for refusing to take part in a criminal act). Indeed, the language
of the streets is ripe with forensic codes and distinctions: people who emerge
from prison commonly speak of having not friends but ‘associates’;
offenders may draw distinctions between ‘commercial’ crime
(robbing a warehouse) and ‘domestic’ crime (robbing a house), the
latter often perceived as less honourable than the former.

1-Hour assessment

Given the peripatetic nature of our service users (many will have already
migrated through several cities before the homeless assessment and support
team meets them), it is crucial to obtain as much information as possible at
the first assessment, while also recognising that some material may be too
sensitive to be divulged early on. We have opted to try to include cognitive,
physical and reading assessments whenever possible (Box 1), as these may
inform diagnosis, prognosis and intervention: those with profound executive
dysfunctions may have little prospect of modulating their behaviours unaided
(Spence et al, 2004);
those with learning disabilities may gain access to more supportive
accommodations; some hostels may provide literacy services for those who are
functionally illiterate, etc.

Additionally, a willingness to examine the homeless person points to the
therapeutic aim of the encounter and the person’s status – they
are not perceived as untouchable. Even measuring blood pressure involves a
moment of silence in which the homeless person is treated as any other medical
patient. They are taken seriously.

‘What’s the worst thing you’ve ever done to someone
else?’

On the face of things, this is a terrible question to ask anyone, yet it
emerged from a need to try to estimate forensic risk in some of our more
sub-optimal interview milieu where there was always the risk of a failure of
follow-up. When sparingly used and sympathetically voiced, the question
requires users to cast their minds back, to think morally and to gauge what
they can tell their interviewer. If they do not trust the interviewer, they
will not answer the question and the interviewer rarely possesses a
priori knowledge of the event described. Nevertheless, certain patterns
can be identified: among homeless men in Sheffield this question frequently
elicits the description of a fight; a professional criminal may begin with ‘
Are you writing this down?’; for women, the worst is often a
child they left behind (‘It was for the best’). The question
rarely elicits a response that is not suffused with some form of sadness,
either at one’s own failures or those of life itself. An ex-professional
criminal became tearful when he admitted that the worst of all his crimes had
been a domestic robbery, because when he brandished a gun he felt for an
instant the terror of his female victim (‘I saw it in her eyes’).
This incident caused him to leave his gang.

Additionally, experience alerts one to answers that are obviously
statistical outliers: over 6 years, the only trivial example offered was from
a man who spoke of kicking sand in another child’s face at the age of 10 –
it later transpired that the man had probably killed. Hence, a trivial
exemplar might well indicate obfuscation.

Bad Samaritans

There is another surprise awaiting those who attempt to treat the homeless:
an apparent resistance on the part of some colleagues
(Timms, 1996). We have
encountered a marked therapeutic nihilism among ward staff.

When we admitted a woman with hebephrenic schizophrenia who had been found
thought disordered in the street, we were approached by a nurse who said that
he had ‘walked past this woman every day for 3 years’ so why was
she being treated now? Admittedly, there is ample scope for confusion here –
if a person has had psychosis for years, then when is a good time to
intervene? In eight roofless individuals with psychosis admitted over the
first 12 months of our service, with reported duration of untreated psychosis
of 1–13 years (mean=5), it was found that despite the early discharge of
two users (one because of alcohol misuse, the other through a mental health
tribunal), six responded to treatment, none of whom required high-dose
medication; all regained permanent accommodation
(Girgis & Spence, 2003). It
may be the case that not treating the homeless becomes a kind of
self-fulfilling prophecy (less charitably construed as prejudice). Certainly,
one of the most frustrating experiences of recent years has been attempting,
over many months, to locate and engage with a man with psychosis who lived
along railway lines, believing he was evading a persecuting demon (he was
recurrently assaulted by gangs of youths but did not blame them because he
attributed their actions to their being remotely controlled by the demon),
then admitting him to hospital one morning only for the nursing staff to send
him ‘home on leave’ the same afternoon. Some might wish to debate
the semantics of home leave for people who have no home. But perhaps more
salient here is the word ‘leave’.

However, there is a serious problem for in-patient staff in the current NHS –
the current value system places emphasis upon the duration of
admission and the need to process as many admissions as quickly as possible,
aiming for care in the community. It seems as if the homeless did not really
fit this concept of medicine, where the model patient seems to be a person who
is not very ill, who has a home to go to and a family to care for them.
Perhaps the nursing staff have a point – current in-patient systems are
not designed for the homeless.

Absent fathers

Individuals who present to psychiatric services commonly have disturbed
familial relations and experiences. However, the homeless in Sheffield exhibit
one very marked feature: nearly all have no father with whom they maintained
contact during childhood and adolescence. Recurrent themes are paternal
abandonment, imprisonment, death, and divorce. Only 5% of those assessed by
the Homeless Assessment and Support Team’s psychiatrist grew up with
their father. The absence of a father cannot be equated with a child’s
predestination towards pathology – indeed, where a father is antisocial
the risk to the child might even be ameliorated by his departure
(Jaffee et al, 2003).
However, it seems likely that a father’s absence systematically exposes
the child to certain experiences: relative poverty, periods in local authority
care, conflict with the stepfather, physical and sexual abuse from new ‘
relatives’, undiluted consequences of maternal mental illness.
The team have seen men who were beaten and sexually abused by their
mothers’ boyfriends, who saw their father solely on visiting days in
prison, who were abused in residential care and rejected by the new family
once they got out, sodomized by older stepsiblings.

From a psychodynamic perspective it would be unsurprising if those
subjected to such experiences subsequently had difficulty in trusting male
authority figures, or if they did not trust female co-workers (akin to those
females who abandoned them as children). It can be particularly hard to
establish rapport with these men once they are already outside society (e.g.
following periods in local authority care, in prison, or in the criminal and
illegal drug using groups). The homeless assessment and support team has tried
to remain available but promise little, offering tangible assistance (with
accommodation) while not pretending to ‘understand’ the
experiences they have had. Most importantly, the team attempts to withhold
judgement. In Winnicott’s memorable terminology, we attempt to be ‘
good-enough’ objects
(Phillips, 1988).

Cycle of rejection

If one permits oneself a psychodynamic consideration of the conditions of
engagement pertaining within ‘homeless psychiatry’, it seems clear
that the service provider is attempting to undo much of what families and
societies have already inflicted upon the homeless service user. Parents have
often been cruel or unreliable, strangers abusive, authority figures a source
of punishment and suspicion – it can be very difficult to make a fresh
start. Yet, the traditional medical response to such people can often seem to
recapitulate rejection (Timms,
1996): letters discharge people from follow-up when appointments
are not kept, their motives are second guessed and symptoms doubted (think of
pain or insomnia), their physical condition may make carers reluctant to touch
them or even to remain in their presence (e.g. without the window being open).
It can be very informative to ask a student to check the pulse of a malodorous
person. How should the teacher respond when the student refuses to touch the
person?

On one acute psychiatric ward, half of the in-patients who missed lunch
each day (across 8 months) because they were still in bed at midday were
homeless (constituting nearly all of those homeless on the ward at the time;
Thomas & Spence, 2005).
Such people withdraw from others and it may require considerable ingenuity and
patience to establish a link. It was later established that returns from acute
psychiatric wards in the trust usually constituted 30–40% of meals, in
contrast to the older adult wards where the nurses took the food to the
patients.

Lost in translation

The size of an ethnic community may constrain the probability of obtaining
an accurate translation in its language. In a city where many of the refugees
seen by the Homeless Assessment and Support Team originate from the Middle
East and the Horn of Africa, obtaining accurate translation poses real
difficulty. There are at least three problems.

Lack of anonymity (in a small community, patient and translator may know
each other).

Factionalism (in those emerging from war-torn countries, patient and
translator may come from opposing sides).

Editing (if the patient is thought disordered, the translator may try to
ameliorate that in their translation; if the subject matter is unacceptable
for the translator, they may try to suppress it, particularly in cultures
where suicidal ideation is considered immoral).

It is difficult to design systems of healthcare where every potential
language is catered for, but the reality of such limitations should at least
be acknowledged (particularly where the ethnic community is itself divided;
Tribe, 2002).

Homeless pharmacology

It might be anticipated that prescribing for homeless people with a mental
illness will be constrained by stark realities and risks
(Timms, 1996). Clinicians are
likely to avoid prescribing the potentially addictive or remunerative
substances (e.g. benzodiazepines, methylphenidate or procyclidine) or those
that require close monitoring (lithium, clozapine or the more recent
anticonvulsants for depression, e.g. lamotrigine). In contrast, relatively
safe antidepressants with a long half-life (e.g. fluoxetine) and depot
preparations of antipsychotics may be favoured because intermittent
non-adherence may be less disruptive.

Homeless psychodynamics

The Homeless Assessment and Support Team does not have access to the
psychotherapies. Often, this is more clinically appropriate anyway (although
there is some preliminary evidence that cognitive–behavioural therapy
may reduce violence and offending behaviours in the homeless;
Maguire, 2006). However, in
some situations most of what the team encounters can be understood in
psychodynamic terms. The concepts of transference, counter-transference,
idealisation and splitting are recurrently made manifest through the conduct
of teams and individuals dealing with this service user group. The people who
are illiterate are often treated with frank disrespect, as are those with
suicidal intentions and addictions. Sometimes the team member has to play the
advocate, witnessing and reflecting back upon the way the person was treated
by other agencies. Once a homeless person has offended someone, be they in the
housing department, the out-patient clinic or the general practice reception
area, it may be very difficult for them to access care
(Timms, 1996). Nevertheless,
we must resist the notion that only our team members understand the
person.

Playing for keeps

Multiple exigencies are likely to be influencing every attempt at follow-up
in the homeless person, for example loss of accommodation, intermittent
financial imperatives, procurement and use of illegal substances, cognitive
impairment, harassment and feuds. Hence, it is especially important for the
staff who work with homeless people to use each contact to maximum effect. A
typical pattern of engagement discernable among the old notes and records of
the homeless (in particular those who have psychosis) is the repeated deferral
of action. It is not unusual for a homeless person with a severe mental
illness to be assessed acutely (perhaps in a police cell or else in an
accident and emergency department), found to be ill but inexplicably
discharged – instead of being admitted, they are offered either a
so-called ‘second chance’ (as if having an illness was a lifestyle
choice) or an out-patient appointment. When the proffered appointment is not
kept, the person is ‘discharged’ from follow-up. How realistic is
such a sequence of decisions? A person who believed themselves possessed was
offered just this form of follow-up and then discharged; another person with
acute mania was given a prescription and an appointment for 2 weeks hence –
how likely was their attendance? Every opportunity to assess a
homeless person should be regarded as potentially the last.

The right stuff

The nature of the work on the homeless assessment team is such that one has
to be able to trust one’s colleagues. Also, although it is trust policy
that outreach visits should not be conducted alone, in reality this is often
the case in a small team. We recommend telephone contact, agreed times of
return to base and joint working with other agencies (Box 2).

Disagreements may arise within the team – these usually concern the
threshold of intervention (e.g. a medic may think mostly about risk, while a
social worker may place greater emphasis upon a person’s autonomy): when
has a cognitively failing street-drinker declined sufficiently to warrant a
guardianship order? How physically frail must he be for this to be
feasible?

Box 2. Lessons learned from the homeless in Sheffield

Keep a flexible approach (emphasis on an ‘outreach’ model)

Maximise utility of first assessment (and each point of contact)

Maintain a non-pejorative attitude, be polite and consistent

Keep in contact (even despite non-adherence; if sending letters, make them
polite and caring)

Maintain liaison with other teams (particularly housing, substance misuse
services, local support agencies)

Judicious use of the multi-agency public protection planning framework

Value the team (keep in contact, have mobile telephone numbers, known
appointment venues, agreed times of return to base)

Appropriate use of pharmacology (safe options, long half-life if
non-adherence is an issue)

Make explicit handover arrangements with appropriate teams when housing has
been secured and tenancy is stable

Futile referrals

A difficulty often emerges when attempting to terminate involvement with
individuals who have finally obtained permanent accommodation. There is a
question of how long such a person has to reside at an address before they can
be admitted to mainstream mental health services. The consequences of failure
can be severe. With homeless people, the routine out-patient appointment and
the discharge letter when they do not attend does not seem to constitute an
adequate response, presuming, as it seems to, that non-attendance is a sign
that all is well. Our experience (and that of others) is that discharging the
person only leads to recurrent homelessness and re-introductions to our
service (Mitchell & Selmes,
2007).

Happy endings

Much of what we have rehearsed here deals with risk and failure: failure to
engage, to maintain a relationship, to access housing or to treat an illness.
However, even in this most highly selected and socially alienated city
population, there is the prospect of redemption, even if it comprises only a
place to live and a secure tenancy. For three-quarters of our service users
the function of the service is fulfilled, in that a home and necessary contact
with mainstream services is achieved
(Girgis & Spence,
2003).

Among spontaneous expression of thanks from parents of the people we have
helped, we have also received a rather more ambiguous reward: an elderly man
with vascular dementia said upon discharge ‘I’ll never forget what
you’ve done for me’.

Conclusions

Attempting to deliver a psychiatric service to homeless people requires a
different type of practice from that of mainstream services and a lower
threshold of suspicion that ‘all is not well’. It requires
attention to detail in obtaining as much information as possible when contact
is made. It also requires an open, non-pejorative approach to people who may
have had exceedingly aberrant early lives. The team must constitute ‘
good-enough’ objects: workers who are not perfect but reliable
and (hopefully) kind. The service users and their setting place specific
constraints upon the pharmacology deployed. The current priorities of
healthcare systems may serve to further disenfranchise the homeless, who may
be hard to engage. Working with such people is not hopeless but it may be very
demanding. However, in most cases it can be successful.

Acknowledgments

Thanks to all the members of the team for their forbearance. I dedicate
this article to the memory of the late Dennis McCourt, a social worker at
Charing Cross Hospital.

THOMAS, S. & SPENCE, S. (2005) In bed at
midday: missing lunch on an acute psychiatric ward. Poster and
abstract presented at Annual Meeting of the Royal College of Psychiatrists,
Edinburgh 20 June 2005 [available on CD].